Abstract
Despite recent striking advances in assisted reproductive technology (ART), poor ovarian response (POR) diagnosis and treatment is still considered challenging. Poor responders constitute a heterogeneous cohort with the common denominator of under-responding to controlled ovarian stimulation. Inevitably, respective success rates are significantly compromised. As POR pathophysiology entails the elusive factor of compromised ovarian function, both diagnosis and management fuel an ongoing heated debate depicted in the literature. From the criteria employed for diagnosis to the plethora of strategies and adjuvant therapies proposed, the conundrum of POR still puzzles the practitioner. What is more, novel treatment approaches from stem cell therapy and platelet-rich plasma intra-ovarian infusion to mitochondrial replacement therapy have emerged, albeit not claiming clinical routine status yet. The complex and time sensitive nature of this subgroup of infertile patients indicates the demand for a consensus on a horizontally accepted definition, diagnosis and subsequent effective treating strategy. This critical review analyzes the standing criteria employed in order to diagnose and aptly categorize POR patients, while it proceeds to critically evaluate current and novel strategies regarding their management. Discrepancies in diagnosis and respective implications are discussed, while the existing diversity in management options highlights the need for individualized management.
Highlights
The development of assisted reproductive technology (ART) during the last four decades has successfully addressed a plethora of infertile couples
As anticipated, it is the inevitable heterogeneity of the characteristics of poor ovarian responders that established difficulties in implementing the Bologna criteria in clinical practice, compromising the notable effort made by European Society of Human Reproduction and Embryology (ESHRE) in classifying patients of poor ovarian response (POR) [32,33,34]
It is imperative that we offer treatment not relying on clinical manifestations and the respective clinical observations but treatment that is tailored according to the varying mechanisms and the pathways involved in leading to the same clinical manifestations and the same diagnosis
Summary
The development of assisted reproductive technology (ART) during the last four decades has successfully addressed a plethora of infertile couples. The noted patient demand to circumvent these issues and provide alternatives has led to the emergence of innovative approaches such as platelet-rich plasma (PRP), stem cell therapy and mitochondrial replacement therapy (MRT) [17,18,19,20,21] It is the lack of consensus and full-proof protocols that challenge clinical routine practice and leave clinicians employing more empirical rather than entirely evidence-based treatment options. This, coupled with the risks entailed in the novel approaches emerging—albeit lacking clinical routine practice status yet—underlines this contribution as timely and essential This critical review aims to present diagnostic tools and scenarios, while the diverse treatment approaches and current options, in the treatment management of poor responders, are discussed. This article attempts a critical analysis of the various novel applications recently emerging as candidates in solving the ‘puzzle’ of effective POR treatment and reporting back to the practitioner, while considerations and concerns towards the divergent options on addressing this heterogeneous population are acknowledged
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